Interventions to decrease distress of living with a diagnosis of Cancer

(From Psychiatric News, April 15, 2021)

Psycho-oncology Services May Reduce Distress, Depression in Cancer Survivors

Outpatient psycho-oncology services, including pharmacotherapy and psychotherapy, significantly reduced distress in cancer survivors up to two years after their diagnosis, according to a study published in Psycho-Oncology.

“Studies which have assessed the effectiveness of psycho-oncology interventions most often did so early in the patient’s cancer treatment course and not in later phases of survivorship,” wrote Jessica Molinaro, M.D., of the Medical College of Wisconsin and colleagues. “As distress is prevalent throughout survivorship, it is imperative that ongoing assessment of psychosocial concerns, intervention on psychological distress, and coordination of care between providers occurs to ensure the needs of the patient are met.”

Molinaro and colleagues recruited 243 patients who had received a cancer diagnosis and were referred to psycho-oncology services. Participants were referred to treatment for a variety of reasons, including difficulty coping with psychosocial stressors or adjusting to cancer diagnoses. Participants had at least one psycho-oncology visit, and the majority were recommended to return for a second visit. They were seen by a physician, nurse practitioner, psychologist, or licensed clinical social worker, all of whom had expertise in psycho-oncology. Interventions included pharmacotherapy and/or psychotherapy. Patients completed the Distress Thermometer and Problem Checklist (DT + PL) and the nine-item Patient Health Questionnaire (PHQ-9), at the beginning of their first and second visits, and the Distress Thermometer again at the end of each visit.

In total, 174 patients had one psycho-oncology visit and 69 had two, with an average of 20 days between visits. The average time from the initial diagnosis of cancer to the first psycho-oncology visit was 2.5 years.

While the patients’ average distress scores before their psycho-oncology visits were clinically significant (defined as a score of ≥4 on the DT), distress scores fell significantly after their sessions and were below the cut-off for clinical significance.

Among patients who had two sessions of a psycho-oncology intervention, PHQ-9 scores were significantly reduced from the first to second visit.

“As distress and depression are prevalent throughout survivorship and associated with adverse outcomes and higher health care costs, identifying an effective outpatient psycho-oncology intervention is highly valuable in improving overall cancer care quality and outcomes,” the authors wrote.

For related information, see the Psychiatric News article “Understanding the Breadth and Depth of the Subspecialty: Psycho-Oncology.”

Reducing distress and depression in cancer patients during survivorship

Jessica MolinaroAnjishnu BanerjeeStanley LyndonSarah Slocum ,Carrie Danhieux‐Poole

Christine Restivo‐Pritzl ,Ann Marie Uselmann ,Lyndsey WallaceJennifer M. Knight

First published: PSYCHO-ONCOLOGY, 01 April 2021,,https://doi.org/10.1002/pon.5683

Abstract

Objective

Distress and depression are prevalent in cancer patients throughout survivorship and are associated with adverse outcomes. This study examines the association between outpatient psycho‐oncology treatment and distress and depression in cancer patients.

Methods

This is a prospective observational study of adult patients with a primary diagnosis of cancer referred for psycho‐oncology services. Patients were seen for two psycho‐oncology visits in a single clinical setting with various qualified providers. Patients completed the distress thermometer and problem checklist (DT + PL) and the Patient Health Questionnaire (PHQ‐9) at the beginning of their first and second visits and repeated the DT at the end of these visits.

Results

The analysis included 174 patients seen once and 69 patients seen twice. Patients were seen on average 2.5 years after diagnosis. Both visits were associated with significant reductions in distress (5.56 before and 3.85 after for visit 1, p < 0.001; 4.92 before and 3.43 after for visit 2, p < 0.001). There was a significant reduction in distress from baseline to after visit 2 (p < 0.001). Depression scores significantly decreased from the first to second visits (8.79–7.57; p = 0.002).

Conclusions

Psycho‐oncology services were associated with significant reductions in distress and depression, with scores after services no longer meeting criteria for clinically significant distress (DT scores ≥ 4) and depression (PHQ‐9 scores ≥ 8) as they did at baseline. Reductions in distress and depression were not significantly associated with provider type, intervention or timing of diagnosis. These findings support the use of psycho‐oncology services in cancer patients throughout survivorship.

Understanding the Breadth and Depth of the Subspecialty: Psycho-Oncology

KIMBERLY MILLER , M.D.,MADELINE LI  M.D., Ph.D.

Published Online:1 Feb 2019https://doi.org/10.1176/appi.pn.2019.2a20

This article is one of a series coordinated by APA’s Council on Consultation-Liaison Psychiatry and the Academy of Consultation-Liaison Psychiatry.

Photo: Kimberly Miller, Madeline Li

Among subspecialties of consultation-liaison psychiatry, psycho-oncology is one of the most well established. The field originated out of the Memorial Sloan-Kettering Cancer Center in New York in the 1950s, growing to its current state with professional organizations in 30 countries comprising the Federation of Psycho-Oncology Societies and establishing and leading Screening for Emotional Distress, the sixth vital sign in medical populations. Psycho-oncology is a multidisciplinary specialty, and cancer psychiatrists are core team members whose role includes assessing a patient’s psychiatric symptomatology; understanding how medical, psychological, and social factors affect the patients’ ability to cope with their illness; and helping the oncology teams develop patient-centered management.

Cancer psychiatrists have expertise in distinguishing between distress that is normative versus maladaptive. They use the etiological approach for psychiatric diagnosis in the context of the somatic consequence of cancer or its treatment; manage psychopharmacology and oncology drug interactions; and psychotherapeutically explore changes in identity and relationships, meaning and purpose, and fears, hope, and mortality.

Case Study

Ms. JS was a 42-year-old single woman with metastatic breast cancer, referred by her oncologist when she declined chemotherapy and requested medically assisted dying instead. She described her cancer as her “way out” of a difficult life filled with trauma, abusive relationships, and loss. Her mother died of advanced cancer when Ms. JS was 8 years old, and she was subsequently raised by an abusive uncle. She had a history of suicide attempts, the last one 15 years ago requiring psychiatric admission. She was lost to follow up after discharge. She described feeling chronically depressed since then, with a significant worsening since her cancer diagnosis two months ago.

After confirming there were no acute safety or capacity concerns, we began by conveying an understanding of how her mistrust had developed in the context of her abusive childhood and adolescence. We shared that our priority would be to develop a trusting relationship with her and to give her as much control over her care as possible. She preferred to avoid intravenous chemotherapy, which would feel intrusive to her and result in hair loss. This was communicated to her oncologist, and she was ultimately treated with tamoxifen, an oral endocrine therapy, and deferred her request for assisted dying. Due to the development of menopause symptoms, together with ongoing and worsening depressive symptoms, she was treated with venlafaxine after brain metastasis was ruled out. Venlafaxine was selected because it is known to alleviate hot flashes and does not interact with tamoxifen, which can occur with other antidepressants.

The scope of a psycho-oncologist includes helping patients with understanding their medical condition and supporting them in their capable treatment decision making. Since psychological suffering is the primary motivation behind assisted-dying requests, over 60 percent of which come from patients with cancer, psycho-oncologists can play a critical role in helping patients explore their options during discussions of care goals. Maintaining communication with the primary oncologist, nurse, social worker, and pharmacist is vital in providing this patient-centered care.

Ms. JS was also engaged in end-of-life psychotherapy. This helped her connect feelings about her past losses to her cancer in the present, which she perceived as another trauma. Over time, she experienced the medical care she received as reminiscent of how her mother had loved her, with compassion and respect. She could recognize her resilience and success in having a stable job and deriving a strong sense of meaning through her work, which she was able to continue throughout most of her two-year illness.

After progression of her disease, the need to control her physical appearance remained very important to her as a way of maintaining a valued aspect of her identity. She agreed to treatment with capecitabine, an oral chemotherapy that does not cause hair loss, and continued on this until a few months before she died. In hospice, she continued to be followed by the psycho-oncology team that she had grown to trust, allowing herself to receive care and dying peacefully.

In addition to the core C-L psychiatric management of medical patients, psycho-oncology provides a unique opportunity to work longitudinally with patients facing life-and-death issues, exploring and responding to existential distress. This in turn requires psychiatrists to be mindful of their own countertransference and well-being in working with this population. It necessitates exquisite professionalism, but at the same time can be a deeply personal experience, both rewarding and poignant. ■

Kimberly Miller, M.D., is an assistant professor of C-L psychiatry at the University of Toronto and an attending psychiatrist and education coordinator in psychosocial oncology in the Department of Supportive Care at the Princess Margaret Cancer Centre.

Madeline Li, M.D., Ph.D., is an associate professor of C-L psychiatry at the University of Toronto, a psychiatrist in the Department of Supportive Care at the University Health Network, and a scientist at the Princess Margaret Cancer Research Institute.

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